Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Rep
*
– select –
Mike Scudder
Bryan Vasquez
Tait Hayden
Aiden Lewer
Scott Smith
Amanda Castonguay
Connor Myers
Jackson Irwin
Connor Harold
Customer Name:
*
First
Last
Address:
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Community:
Phone (Cell):
Phone (Landline):
Email
*
Home Information
How existing (copy)
How many levels?
– select –
1
2
3
4
5
How many bedrooms?
– select –
1
2
3
4
5
Square footage:
Age of home (years):
Fuse or Breaker Panel:
– select –
Fuse
Breaker
Electrical Panel Size:
Heating / Cooling Information
Heat Source
– select –
Electric BB
Furnace/Wood
OIL
Propane / Natural Gas
Existing Heat Pump
Annual Cost for Electric Heat:
60% of Cost:
Do you use Air Conditioners?
– select –
Yes
No
If yes, how many in the home?
– select –
1
2
3 or more
Annual Heating Cost:
Total Household Income:
Level of interest to get a heat pump?
– select –
1
2
3
4
5
6
7
8
9
10
How many people in the home?
Existing Heat Pump
Do you want to replace your existing Heat Pump?
Yes
No
Ducted or Ductless
Ducted
Ductless
Do you have an existing Heat Pump but want to cover more areas?
Yes
No
Are you looking to service an existing Heat Pump?
Yes
No
If OIL – Check all documents you have ready for Assessment:
Tax Notice of Assessment (For all employee people of the home)
Property Tax Document stating you own the home
Oil receipts of over 500L used within the last 12 months
Power/Hydro Company Account Number
Notes
Preferred Method of Contact
*
Phone
Text
Email
Appointment
*
Time Of Day
*
– Select –
AM
PM
EVENING
Submit
